NOTICE: This report is required by 49 CFR Part 195. Failure to report can result in a civil penalty not to exceed $25,000 for each violation Form Approved for each day that such violation persists except that the maximum civil penalty shall not exceed $500,000 as provided in 49 USC 60122 OMB No. 2137-0047

U.S. Department of Transportation Research and Special Programs Administration

ACCIDENT REPORT – HAZARDOUS LIQUID PIPELINE SYSTEMS

Report Date No.

(DOT Use Only)

INSTRUCTIONS

Important: Please read the separate instructions for completing this form before you begin. They clarify the information requested and provide specific examples. If you do not have a copy of the instructions, you can obtain one from the Office Of Pipeline Safety Web Page at http://ops.dot.gov.

PART A – GENERAL REPORT INFORMATION Check: Original Report Supplemental Report Final Report

1. a. Operator's OPS 5-digit Identification Number (if known) / / / / / / 2. b. If Operator does not own the pipeline, enter Owner’s OPS 5-digit Identification Number (if known) / / / / / / c. Name of Operator ______________________________________________________________________________________

d. Operator street address _______________________________________________________________________________ e. Operator address ______________________________________________________________________________________ City, County, State and Zip Code

IMPORTANT: IF THE SPILL IS SMALL, THAT IS, THE AMOUNT IS AT LEAST 5 GALLONS BUT IS LESS THAN 5 BARRELS, COMPLETE THIS PAGE ONLY, UNLESS THE SPILL IS TO WATER AS DESCRIBED IN 49 CFR §195.52(A)(4) OR IS OTHERWISE REPORTABLE UNDER §195.50 AS REVISED IN CY 2001.

2. Time and date of the accident

/ / / / / / / / / / / / / / hr. month day year

3. Location of accident (If offshore, do not complete a through d. See Part C.1) a. Latitude: _____ Longitude: __________ (if not available, see instructions for how to provide specific location) b. _________________________________________________ City, and County or Parish

c. _________________________________________________ State and Zip Code

d. Mile post/valve station or survey station no.

(whichever gives more accurate location) _________________________________

4. Telephone report

/ / / / / / / / / / / / / / / / NRC Report Number month day year

5. Losses (Estimated) Public/Community Losses reimbursed by operator: Public/private property damage $_______________ Cost of emergency response phase $_______________ Cost of environmental remediation $_______________ Other Costs $_______________ (describe) _____________________________________ Operator Losses:

Value of product lost $_______________

Value of operator property damage $_______________

Other Costs $_______________ (describe) _____________________________________

Total Costs $_______________

6. Commodity Spilled Yes No

(If Yes, complete Parts a through c where applicable)

a. Name of commodity spilled ___________________________

b. Classification of commodity spilled: HVLs /other flammable or toxic fluid which is a gas at ambient conditions

CO2/ N2 or other non-flammable, non-toxic fluid which is a gas at ambient conditions

Gasoline, diesel, fuel oil or other petroleum product which is a liquid at ambient conditions

Crude oil

c. Estimated amount of commodity involved :

Barrels

Gallons (check only if spill is

less than one barrel)

Amounts: Spilled : ____________ Recovered: ____________

CAUSES FOR SMALL SPILLS ONLY (5 gallons to under 5 barrels) : (For large spills [5 barrels or greater] see Part H)

Corrosion Natural Forces Excavation Damage Other Outside Force Damage

Material and/or Weld Failures Equipment Incorrect Operation Other

PART B – PREPARER AND AUTHORIZED SIGNATURE

(type or print) Preparer's Name and Title

Area Code and Telephone Number

Preparer's E-mail Address

Area Code and Facsimile Number

Authorized Signature (type or print) Name and Title

Date

Area Code and Telephone Number

Form RSPA F 7000-1 ( 01-2001 ) Page 1 of 4

Reproduction of this form is permitted

OPERATOR_ID

RPTID

OWNER_OPERATOR_ID

NAME OPSTREET

OPCITY OPCOUNTY OPSTATE OPZIP

IHOUR IDATE

ACCITY ACCOUNTY

ACSTATE ACZIP

LATITUDE LONGITUDE

MPVST SURNO

TELRN TELDT

PPPRP

EMRPRP ENVPRP OPCPRP

OPCPRPO

PRODPRP

OPPRP

OOPPRP OOPPRPO

PRPTY

SPILLED

COMM

CLASS_TXT CLASS

SPUNIT SPUNIT_TXT

LOSS

RECOV

GEN_CAUSE GEN_CAUSE_TXT

PNAME PTEL

PEMAIL PFAX

PART C – ORIGIN OF THE ACCIDENT (Check all that apply)

1. Additional location information a. Line segment name or ID _______________________ b. Accident on Federal land other than Outer Continental

Shelf Yes No

c. Is pipeline interstate? Yes No

Offshore: Yes No (complete d if offshore)

d. Area ___________________ Block # ______________

State / / / or Outer Continental Shelf

2. Location of system involved (check all that apply)

Operator’s Property

Pipeline Right of Way

High Consequence Area (HCA)?

Describe HCA____________________________________

3. Part of system involved in accident

Above Ground Storage Tank

Cavern or other below ground storage facility

Pump/meter station; terminal/tank farm piping and

equipment, including sumps

Other Specify: _________________________________

Onshore pipeline, including valve sites

Offshore pipeline, including platforms

If failure occurred on Pipeline, complete items a - g: 4. Failure occurred on

Body of Pipe Pipe Seam Scraper Trap

Pump Sump Joint

Component Valve Metering Facility

Repair Sleeve Welded Fitting Bolted Fitting Girth Weld

Other (specify)

Year the component that failed was installed: / / / / / 5. Maximum operating pressure (MOP) a. Estimated pressure at point and time of accident:

____ PSIG b. MOP at time of accident:

___________PSIG c. Did an overpressurization occur relating to the accident?

Yes No

a. Type of leak or rupture

Leak: Pinhole Connection Failure (complete sec. H5)

Puncture, diameter (inches) _________

Rupture: Circumferential – Separation

Longitudinal – Tear/Crack, length (inches) ___________

Propagation Length, total, both sides (feet) _________

N/A Other _______________________________

b.Type of block valve used for isolation of immediate section: Upstream: Manual Automatic Remote Control

Check Valve

Downstream: Manual Automatic Remote Control

Check Valve

c. Length of segment isolated _______ ft

d. Distance between valves _______ ft

e. Is segment configured for internal inspection tools? Yes No f. Had there been an in-line inspection device run at the point of

failure? Yes No Don’t Know

Not Possible due to physical constraints in the system

g. If Yes, type of device run (check all that apply)

High Resolution Magnetic Flux tool Year run: ______

Low Resolution Magnetic Flux tool Year run: ______ UT tool Year run: ______ Geometry tool Year run: ______

Caliper tool Year run: ______ Crack tool Year run: ______ Hard Spot tool Year run: ______

Other tool Year run: ______

PART D – MATERIAL SPECIFICATION PART E – ENVIRONMENT

1. Nominal pipe size (NPS) / / / / / in.

2. Wall thickness / / / / / in.

3. Specification SMYS / / / / / / / 4. Seam type 5. Valve type 6. Manufactured by in year / / / / /

1. Area of accident In open ditch

Under pavement Above ground

Underground Under water

Inside/under building Other ____________

2. Depth of cover: inches

PART F – CONSEQUENCES

1. Consequences (check and complete all that apply)

a. Fatalities Injuries c. Product ignited Yes No d. Explosion Yes No

Number of operator employees: _______ _______ e. Evacuation (general public only) / / / / / people

Contractor employees working for operator: _______ _______ Reason for Evacuation:

General public: _______ _______ Precautionary by company

Totals: _______ _______ Evacuation required or initiated by public official

b. Was pipeline/segment shutdown due to leak? Yes No f. Elapsed time until area was made safe:

If Yes, how long? ______ days ______ hours _____ minutes / / / hr. / / / min.

2. Environmental Impact

a. Wildlife Impact: Fish/aquatic Yes No e. Water Contamination: Yes No (If Yes, provide the following)

Birds Yes No Amount in water _________ barrels

Terrestrial Yes No Ocean/Seawater No Yes

b. Soil Contamination Yes No Surface No Yes

If Yes, estimated number of cubic yards: _________ Groundwater No Yes

c. Long term impact assessment performed: Yes No Drinking water No Yes (If Yes, check below.)

d. Anticipated remediation Yes No Private well Public water intake If Yes, check all that apply: Surface water Groundwater Soil Vegetation Wildlife

Form RSPA F 7000-1 ( 01-2001 ) Page 2 of 4

Reproduction of this form is permitted

LINE_SEG

INTER

OFFSHORE

OFFAREA

IFED

BNUMB

OFFST OCS

OPPROP PIPEROW

HCA HCADESC

SYSPRT SYSPRT_TXT

SYSPRTO

FAIL_OC FAIL_OC_TXT

FAIL_OCO PRTYR

INC_PRS

MOP

OPRS

LRTYPE LRTYPE_TXT

LRTYPEO

LEAK LEAK_TXT PUNC_DIAM

UBLKV *

RUPTURE RUPTURE_TXT RUPLN PROPLN

DBLKV * SEGISO VLVDIST SEGCONF

INLINE INLINE_TXT

DRHRMF DRHRMFY DRLRMF

DRLRMFY DRUT DRUTY DRGEO DRGEOY DRCAL DRCALY DRCRK DRCRKY DRHARD DRHARDY DROTH DROTHY

NPS WALLTHK

SPEC SMYS

SEAM VALVE

MANU MANYR

LOCLK

FATAL

EFAT

NFAT

GPFAT

INJURE

EINJ

LOCLK_TXT

LOCLKO

DEPTH_COV

NINJ

GPINJ

SHUTDOWN

SHUTDAY SHUTHR SHUTMIN

IGNITE EXPLO

EVAC EVACNO

EVAC_REASON EVAC_REASON_TEXT

FISH BIRDS TERRESTRIAL

SOIL SOIL_YRD

IMPACT REMEDIAL

STHH STMN

RSURFACE RGROUND RSOIL RVEG RWILD

WATER

AMT_IN_WATER OCEAN SURFACE GROUNDW

DRINK

DRINKSRC DRINKSRC_TXT

A R C

M

M A R C

PART G – LEAK DETECTION INFORMATION

1. Computer based leak detection capability in place? Yes No

2. Was the release initially detected by? (check one): CPM/SCADA-based system with leak detection

Static shut-in test or other pressure or leak test

Local operating personnel, procedures or equipment

Remote operating personnel, including controllers

Air patrol or ground surveillance

A third party Other (specify) _________________ 3. Estimated leak duration days ____ hours ____

PART H – APPARENT CAUSE Important: There are 25 numbered causes in this Part H. Check the box corresponding to the primary cause of the accident. Check one circle in each of the supplemental categories corresponding to the cause you indicate. See the instructions for guidance.

H1 – CORROSION

1. External Corrosion

2. Internal Corrosion

(Complete items a – e where applicable.)

a. Pipe Coating

Bare

Coated

b. Visual Examination

Localized Pitting

General Corrosion

Other ____________________

c. Cause of Corrosion

Galvanic Atmospheric

Stray Current Microbiological

Cathodic Protection Disrupted

Stress Corrosion Cracking

Selective Seam Corrosion Other ____________________

d. Was corroded part of pipeline considered to be under cathodic protection prior to discovering accident?

No Yes, Year Protection Started: / / / / /

e. Was pipe previously damaged in the area of corrosion?

No Yes Estimated time prior to accident: / / / years / / / months Unknown

H2 – NATURAL FORCES

3. Earth Movement Earthquake Subsidence Landslide Other

4. Lightning

5. Heavy Rains/Floods Washouts Flotation Mudslide Scouring Other

6. Temperature Thermal stress Frost heave Frozen components Other

7. High Winds

H3 – EXCAVATION DAMAGE

8. Operator Excavation Damage (including their contractors/Not Third Party)

9. Third Party (complete a-f)

a. Excavator group

General Public Government Excavator other than Operator/subcontractor

b. Type: Road Work Pipeline Water Electric Sewer Phone/Cable

Landowner-not farming related Farming Railroad

Other liquid or gas transmission pipeline operator or their contractor

Nautical Operations Other ________

c. Excavation was: Open Trench Sub-strata (boring, directional drilling, etc…)

d. Excavation was an ongoing activity (Month or longer) Yes No If Yes, Date of last contact /___/___/___/ e. Did operator get prior notification of excavation activity?

Yes; Date received: / / / mo. / / / day / / /___/___/ yr. No

Notification received from: One Call System Excavator Contractor Landowner

f. Was pipeline marked as result of location request for excavation? No Yes (If Yes, check applicable items i - iv)

i. Temporary markings: Flags Stakes Paint

ii. Permanent markings: iii. Marks were (check one) : Accurate Not Accurate

iv. Were marks made within required time? Yes No H4 – OTHER OUTSIDE FORCE DAMAGE

10. Fire/Explosion as primary cause of failure Fire/Explosion cause: Man made Natural

11. Car, truck or other vehicle not relating to excavation activity damaging pipe

12. Rupture of Previously Damaged Pipe

13. Vandalism

Form RSPA F 7000-1 ( 01-2001 ) Page 3 of 4 Reproduction of this form is permitted

COMP_BASED

DETECTED DETECTED_TXT

DETECTEDO DURLEAK_DAY DURLEAK_HR

CAUSE CAUSE_TXT PIPE_COAT,,

PIPE_COAT_TXT VIS_EXAM VIS_EXAM_TXT

VIS_EXAMO

COR_CAUSE COR_CAUSE_TXT

COR_CAUSEO PROT

CPYR PREV_DAM

PREV_DAM_UK

FLOODS_TXT FLOODSO

PREV_DAM_YR PREV_DAM_MO

EARTH_MOVE EARTH_MOVE_TXT EARTH_MOVEO

FLOODS

TEMPER TEMPER_TXT TEMPERO

THIRD_PARTY_GRP THIRD_PARTY_GRP_TXT

THIRD_PARTY_TYPE THIRD_PARTY_TYPE_TXT

THIRD_PARTY_TYPEO EXCAV_TYPE EXCAV_TYPE_TXT

EXCAV_ON EXCAV_LAST_CONTACT

NOTIF NOTIF_DATE

NOTIF_RCVD_TXT MARKED TEMP_MARK TEMP_MARK_TXT PERM_MARK ACC_MARK ACC_MARK_TXT MKD_IN_TIME

FIRE_EXPLO FIRE_EXPLO_TXT

H5 – MATERIAL AND/OR WELD FAILURES

Material

14. Body of Pipe Dent Gouge Bend Arc Burn Other

15. Component Valve Fitting Vessel Extruded Outlet Other

16. Joint Gasket O-Ring Threads Other

Weld

17. Butt Pipe Fabrication Other

18. Fillet Branch Hot Tap Fitting Repair Sleeve Other

19. Pipe Seam LF ERW DSAW Seamless Flash Weld

HF ERW SAW Spiral Other

Complete a-g if you indicate any cause in part H5.

a. Type of failure:

Construction Defect Poor Workmanship Procedure not followed Poor Construction Procedures

Material Defect

b. Was failure due to pipe damage sustained in transportation to the construction or fabrication site? Yes No

c. Was part which leaked pressure tested before accident occurred? Yes, complete d-g No

d. Date of test: / / / / / yr. / / / mo. / / / day

e. Test medium: Water Inert Gas Other

f. Time held at test pressure: / / / hr.

g. Estimated test pressure at point of accident: PSIG

H6 – EQUIPMENT

20. Malfunction of Control/Relief Equipment Control valve Instrumentation SCADA Communications

Block valve Relief valve Power failure Other

21. Threads Stripped, Broken Pipe Coupling Nipples Valve Threads Dresser Couplings Other

22. Seal Failure Gasket O-Ring Seal/Pump Packing Other

H7 – INCORRECT OPERATION

23. Incorrect Operation

a. Type: Inadequate Procedures Inadequate Safety Practices Failure to Follow Procedures

Other _______________________________________

b. Number of employees involved who failed a post-accident test: drug test: / / / / alcohol test /___/___/___/

H8 – OTHER

24. Miscellaneous, describe:

25. Unknown

Investigation Complete Still Under Investigation (submit a supplemental report when investigation is complete)

PART I – NARRATIVE DESCRIPTION OF FACTORS CONTRIBUTING TO THE EVENT (Attach additional sheets as necessary)

Form RSPA F 7000-1 (01-2001 ) Page 4 of 4

Reproduction of this form is permitted

TEST_MED TEST_MED_TXT

PIPE_BODY PIPE_BODY_TXT PIPE_BODYO

COMPONENT COMPONENT_TXT COMPONENTO

JOINT JOINT_TXT JOINTO

BUTT BUTT_TXT BUTTO

FILLET FILLET_TXT FILLETO

PIPE_SEAM PIPE_SEAM_TXT PIPE_SEAMO

FAIL_TYPE FAIL_TYPE_TXT

PIPE_DAMAGE

PRS_TEST

TEST_DATE

CONS_DEF CONS_DEF_TXT

TEST_MEDO

TEST_TP TEST_PRS

MALFUNC MALFUNC_TXT

MALFUNCO THREADS

SEAL SEAL_TXT SEALO

THREADS_TXT THREADSO

IO_TYPE IO_TYPE_TXT

IO_TYPEO IO_DRUG IO_ALCO

MISC

UNKNOWN UNKNOWN_TXT

NARRATIVE

Note: Field names not on the form are as following: Field Name

Field Name Description

IYEAR Year accident occurred, derived from accident date